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UM Guidelines
Skilled Nursing Facility Admission for Enhanced Respiratory Care - Ventilator Weaning - For BlueCare Use Only

Line of Business Specific Guidelines - Recovery Facility Care

BCBST last reviewed April 11, 2019*

 

 

Applies to BlueCare Only.

Evidence Summary

Prolonged mechanical ventilation (PMV) is associated with some of the highest costs in medical care. The care of ventilator patients accounts for approximately 37% of all ICU cases and utilizes vast resources through clinical care needs and from the standpoint of case management resources. (5)

PMV has been variously defined but a common, accepted (e.g., expert panel consensus, used in peer-reviewed research on the topic) definition is an episode wherein a patient requires mechanical ventilatory support for 6 or more hours a day for 21 days. (7) (8) (9) (10) (11) Whatever the specific method of weaning employed, the vast majority of newly intubated patients are successfully extubated well before 21 days. (16)

A randomized study examining 500 patients transferred to post-acute care after more than 21 days of mechanical ventilation found that 32% of patients passed an initial spontaneous breathing trial upon arrival at the facility and were rapidly liberated, highlighting the need to be aggressive in ICU-based weaning trials and to be cautious in prematurely labeling a patient ventilator-dependent.(10) An accompanying editorial concludes that this data, showing such a high rate of initial ability to wean, suggests that a significant proportion of patients sent to post-acute care due to failure to wean may instead have experienced failure to adequately attempt to wean in the acute care hospital.(31) This same trial then randomized the remaining truly ventilator-dependent patients admitted to post-acute care with a weaning strategy of reducing pressure-supported ventilation or spontaneous breathing trials through a tracheostomy collar and found that the spontaneous breathing strategy did not result in a higher proportion of patients successfully weaned but did shorten the median time to successful weaning (11 days vs 16 days). (10) Various studies have reported ventilator liberation rates ranging between 51% and 67% in post-acute settings. (11) (32) (33) (34) (36) (37) (38)

Patients undergoing PMV should continue to be evaluated for weaning potential in the post-acute environment. Given appropriate time and effort a substantial number of the subgroup can be successfully removed from mechanical ventilation and liberated. (33) (38)

Clinical Indications for Admission to Recovery Facility

Hospital Care Planning Criteria for Active Weaning

Length of Stay and Rehabilitation Frequency

Goal Length of Stay: 7-days

Best Practice Recommendations